Dementias

1
Dementias

• As of 4Feb2015. All items from DSM-IV, DSM-5, APA
  Practice Guidelines, Taman/Mohr Text, or
  Sadock/Sadock/Ruiz Text unless otherwise
  indicated.

2
Dx criteria

• Q. What is the outline of the DSM dx criteria of
  dementia?

3
Dx criteria - general

• Ans.
• 1. Multiple cognitive deficits.
• 2. Gradual onset and decline
• 3. Not part of another Disorder

4
Dx criteria Specific Cognitive deficits

• Q. What cognitive deficits are part of the DSM
  criteria of dementia?

5
Dx specific cognitive deficits

• Ans.
• 1. Memory impairment
• AND
• 2. At least one of the following
• Aphasia
• Apraxia
• Agnosia
• Executive functioning deficits

6
Early onset

• Q. What is the dividing line between early and
  late onset dementia?

7
Early Onset

• Ans.
• lt or 65, early onset
• gt 65, late onset

8
Reasons to hospitalize

• Q. List reasons to hospitalize pts with dementia.

9
Reasons to hospitalize

• Ans.
• 1. Symptom severity
• Dangerousness to self or others, including
  inability of caretakers to care for the pt
• 2. Intensity of care and treatment needed
• -- evaluations or treatments that cannot by done
  on outpt basis.

10
Follow-up

• Q. If you have a routine pt with Alzheimers,
  how often should the pt be monitored by you?

11
Follow-up

• Ans. Every 3 to 6 months.

12
MMSE

• Q. What is the MMSE? And What does it evaluate?

13
MMSE

• Ans.
• MMSE Mini-mental status examination.
• MMSE tests cognitive functioning.

14
CT or MRI

• Q. When is CT or MRI advised as part of the
  initial eval of people with dementia?

15
CT or MRI

• Ans. Some would say in all, but the question is
  more likely to focus on when one of these tests
  is more indicated than most pts with dementia
• Early onset
• Relatively rapid onset
• High vascular risk factors suggested
• Neurological exam suggests local lesions

16
Neuropsych testing

• Q. When is neuropsych testing indicated?

17
Neuropsych testing

• Ans. When questions arise as to whether the
  individual actually has a dementia.
• Keep in mind that only Mental Retardation and
  Learning Disorders has psychological testing as
  part of a DSM criteria set.

18
Gene testing

• Q. Is gene testing recommended?

19
Gene testing

• Ans. Gene testing is not recommended. Dx is
  clinically based regardless of genes. See
  exceptions infra

20
Apolipoprotein E-4

• Q. What is the significance of apolipoprotein E-4
  (APOE-4)?

21
Apolipoprotein E-4

• Ans. Apolipoprotein E-4 APOE-4, on chromosome
  19, is more common in individuals with
  Alzheimers but not diagnostic.

22
Suicidal

• Q. At what stage of a dementia is suicidal
  ideation most common?

23
Suicidal

• Ans. Most common when the disease is still mild.

24
Suicide and gender

• Q. Which gender is suicide most common in this
  illness?

25
Suicide and gender

• Ans. Men
• In answering exam questions as to successful
  suicides, keep in mind that men do so far more
  often than women, and that is even more true in
  the elderly.

26
Falls

• Q. Give one of major ways a physician can reduce
  the chances of falls in pts with dementia.

27
Falls

• Ans. Review and considered discontinuance of meds
  associate with falls.

28
Driving

• Q. Should a physician report their patient who
  has dementia to the state department of motor
  vehicles?

29
Driving

• Ans. Varies by state. Required in some,
  forbidden in others.

30
Dosing in the elderly

• Q. What are the principles of medicating in the
  elderly?

31
Medicating the elderly

• Ans.
• -- lower starting doses.
• -- longer intervals between dose increases.
• -- smaller dose increase

32
Medicating rules - why

• Q. Why the go-slow approach with the elderly?

33
Medicating rules - why

• Ans.
• slower hepatic metabolism
• decreased renal clearance

34
Goal of medicating

• Q. What is the goal of medicating a patient with
  Alzheimers?

35
Goal of medicating

• Ans. Delay progression of the disease. No med
  reverses.

36
FDA for Alzheimers

• Q. What meds have been approved for Alzheimers?

37
FDA for Alzheimers

• Ans.
• donepezil
• galantamine
• memantine
• rivastigmine
• tacrine

38
FDA med action

• Q. Which of the five is/are cholinesterase
  inhibitors? Which is/are NMDA antagonist?

39
Meds - actions

• Ans.
• donepezil, galantamine, rivastigmine, and
  tacrine are cholinesterase inhibitors.
• memantine is a noncompetitive N-methyl-aspartate
  antagonist, glutamate antagonist.

40
Vitamin E

• Q. What about high doses of Vitamin E for
  Alzheimers?

41
Vitamin E

• Ans. Not proven to be useful and high doses may
  be associated with increased risk of heart
  failure.
• Vitamin E must be avoided in patients with
  vitamin K deficiencies.

42
Q. Selegiline

• 1 Selegilines usefulness in dementia?
• 2 Especially problematic?

43
Ans. Selegiline

• 1 Not proven to be useful.
• 2 Should not be given to pt on an
  antidepressant.

44
Tacrine

• Q. Tacrine status?

45
Tacrine

• Ans. Regarded as less preferred to donepezil,
  rivestigmine, and galantamine because of
  tacrines hepatic toxicity.

46
ECT

• Q. Indications for ECT in pts with Alzheimers?

47
ECT

• Ans. Indicated for pts with moderate to severe
  depression and Alzheimers and who do not respond
  to or cannot tolerate antidepressant meds.

48
Delusions and hallucinations

• Q. Pt is moderately impaired from Alzheimers,
  has delusions and hallucinations and is not
  distressed or agitated, meds?

49
Hallucinations and delusions

• Ans. No meds, instead reassurance, redirection
  and distractions.

50
Hallucinations and delusions

• Q. Alzheimers pt with hallucinations and
  delusions and combative, meds?

51
Hallucinations and delusions

• Ans. Low dose antipsychotic.
• This is true of the Guides. Recent FDA warnings
  would suggest ordering antipsychotics at quite
  low levels to begin -- given the increased death
  rate of the elderly on antipsychotics.

52
Profoundly impaired

• Q. What meds help the cognition of the severely
  impaired?

53
Profoundly impaired

• Ans. Memantine is approved for the profoundly
  impaired. Cholinesterase inhibitors are not.

54
Meds Delirium

• Q. What classes of meds can cause delirium in
  those with Alzheimers?

55
Delirium meds

• Ans. Virtually all psychotropic meds, even more
  so, those having anticholinergic activity.

56
Anticholinergic

• Q. What are some meds psychiatrists use that have
  anticholinergic activity?

57
Anticholinergic

• Ans. Tricyclics, low-potency antipsychotics, and
  diphenhydramine.

58
Dopaminergic meds

• Q. Dopaminergic meds used in Parkinsons disease
  in pt who also has Alzheimers predisposes that
  pt to?

59
Dopaminergic meds

• Ans. Visual hallucinations

60
Vascular dementia

• Q. Treatment for vascular dementia?

61
Vascular dementia

• Ans.
• -- control BP
• -- low-dose aspirin
• 2 of 3 trials with donepezil found some positive
  results, but the 3rd trial lack of effectiveness
  probably precludes it being the correct answer.

62
Fronto-temporal dementia

• Q. What med has been shown to decrease
  problematic behaviors of fronto-temporal
  dementia, e.g., agitation?

63
Fronto-temporal dementia

• Ans. Trazodone.
• If trazodone is not one of the choices,
  amantadine has some anecdotal support.

64
Caregivers and depression

• Q. To what degree does depression occur in
  caregivers?

65
Caregivers and depression

• Ans.
• 30 of spousal care-givers experience a
  depressive disorder.
• 22-37 of adult children care-givers, the higher
  percentage, gt 30, in those with a prior hx of a
  mood disorder.

66
Federal Regulation

• Q. A major law, passed in 1987, that regulates
  the use of physical restraints and use of meds in
  nursing home is?

67
Federal Regulation

• Ans. The Omnibus Budget Reconciliation Act of
  1987 OBRA.

68
Gender

• Q. In Alzheimers, which gender is more frequent?

69
Gender

• Ans. More common in women.

70
African Americans

• Q. Relative to Caucasians, Which dementias do
  African Americans have more and which do they
  have less?

71
African Americans

• Ans. More vascular dementia could guess from
  their higher hypertension rate and less
  Parkinsonian dementias.

72
Family Hx

• Q. If Mrs. X has Alzheimers, what the chances of
  her siblings or children getting Alzheimers?

73
Family hx

• Ans. Two to four times that of the general
  population.

74
Genes early onset

• Q. What are the three genes that have an
  increased association with early on-set
  Alzheimers?

75
Genes early onset

• Ans.
• 1. Amyloid precursor protein APP on chromosome
  21
• 2. Presenilin 1 PSEN1 on chromosome 14
• 3. Presenilin 2 PSEN2 on chromosome 1

76
Vascular dementia

• Q. Onset and course of vascular dementia?

77
Vascular dementia

• Ans. Acute onset and step-wise decline.

78
Alzheimers onset - age

• Q. Give the approximate onset of Alzheimers per
  the age of the individual, such as per year of
• lt 65
• 65-70
• 70-75
• 75-80
• 80-85
• gt85

79
Alzheimers onset - age

• lt 65 rare
• 65-70 0.5/ year i.e., one in 200 will develop
  Alzheimers within a year
• 70-75 1
• 75-80 2
• 80-85 3
• gt85 8 Means that the odds of someone who does
  not have Alzheimers at 85 has an 8 chance of
  having the onset over the next 12 months. The
  jump from 3 to 8 doesnt seem correct for 85
  y/o compared to 84 y/o, so the 8 percent must
  be based on the average of all over 85. Im not
  sure.

80
Mild cognitive impairment

• Q. Criteria for mild cognitive impairment?

81
Mild cognitive impairment

• 1. Subjective memory complaints
• 2. Objective cognitive deficits on testing
• 3. Functioning OK

82
Vascular dementia - onset

• Q. Relative to age, what is the incidence of the
  onset of vascular dementia?

83
Vascular dementia - onset

• Ans. Gradually increases with age, so forms an
  increased percentage of those with neurocognitive
  disorders with age, such as those gt85. More
  common in men.

84
Lewy body disease

• Q. Lewy body disease differs in clinical
  presentation from Alzheimers in what ways?

85
Lewy body disease

• Ans. Differs
• -- early and more prominent visual hallucinations
• -- early and more prominent Parkinsonian features
  leading to falls
• -- more rapid decline

86
Lewy body disease - meds

• Q. When you decide to prescribe antipsychotic
  medications to someone with Lewy body disease
  has, what prominent signs are your concern?

87
Lewy body disease - meds

• Ans. Very sensitive to extrapyramidal signs.

88
Frontotemporal dementia

• Q. Characteristics of frontotemporal dementia in
  comparison to Alzheimers?

89
Frontotemporal dementia

• Ans.
• -- personality change early
• -- apathy early
• -- emotional blunting early
• -- disinhibition early
• -- language abnormalities early
• -- memory problems late
• -- apraxia late
• the examiner may use Picks disease for this
  entity
• Hard to remember all 7 items, but recalling that
  memory is relatively late may get you the correct
  answer.

90
Frontotemporal dementia - onset

• Q. Common age of onset?

91
Frontotemporal dementia - onset

• Ans. Onset tends to be between 50 and 60.

92
Huntingtons disease - gene

• Q. Genetic aspect of Huntingtons?

93
Huntingtons - genes

• Ans. Autosomal dominate.

94
Huntingtons - pathology

• Q. Pathology of Huntingtons?

95
Huntingtons - pathology

• Ans. While there is damage to many subcortical
  structures, the answer they are probably looking
  for is basal ganglia.

96
Creutzfeldt-Jakob disease - etiology

• Q. What two etiologies are seen in this disease?

97
Creutzfeldt-Jakob disease - etiology

• Ans.
• -- slow virus
• OR
• -- a prion proteinaceous infectious particle

98
Tardive Diskinesia risks

• Q. Relatively to age, gender, and dementia, what
  are TD risks when using antipsychotics?

99
TD risks

• Ans. Relative to use of antipsychotics, increased
  risk
• 1. in women,
• 2. increased risk in the elderly and
• 3. increased in those with dementia

100
delirium

• Q. What meds used in psychiatry are associated
  with delirium when used with people with
  Alzheimers?

101
delirium

• Ans. Virtually all Practice Guideline

102
Exercise

• Q. Role of exercise in pts with Alzheimers?

103
Exercise

• Ans. Reduces depression in addition to other
  health benefits.

104
MMSE moderate level

• Q. Moderate level of dementia is associated with
  what MMSE score?

105
MMSE moderate level

• Ans. 9 -18.

106
Alzheimers Neuropathology?
107
Ans. Alzheimers Neuropathology

• 1 Flattened cortical sulci
• 2 Enlarged cerebral ventricles
• 3 Senile plaques
• 4 Neurofibrillary tangles
• 5 Neuronal loss, especially in the cortex and
  hippocampus
• 6 Granulovascular degeneration in the neurons

108
Also seen in?

• Neuropathology of Alzheimers also seen in?

109
Ans. Also seen in.

• 1 Downs
• 2 Dementia pugilistica
• 3 Parkinson-dementia complex of Guam
• 4 Hallervoren-Spatz Disease
• 5 Familial Multiple System Taupathy
• 6 Normals as they age

110
Senile PlaquesComposed of?
111
Senile PlaquesComposed of

• Beta/A4

112
Neurotransmitters Often Implicated in
Alzheimers?
113
Neurotransmitters OftenImplicated in Alheimers

• 1 Acetylcholine, hypoactive
• 2 Norepinephrine, hypoactive

114
Cholinergic Antagonists?

• Two cholinergic antagonists that impair cognitive
  ability?

115
Cholinergic Antagonists

• 1 Scopolamine
• 2 Atropine
• Not complete, but likely to reach questions.

116
Cholinergic Agonists?

• Name of cholinergic agonists that would enhance
  cognition?

117
Cholinergic Agonist

• Physostigmine

118
Vascular Dementia Seen In?

• Gender?
• Medical History?

119
Vascular DementiaIs Seen In

• Men with hypertension

120
Binswangers Disease?

• Pathology of Binswangers Disease?

121
Binswangers Disease

• Many small infarcts of the white matter that
  spares the cortical region.

122
Picks DiseasePathology?
123
Picks DiseasePathology

• Also called Frontotemporal Dementia.
• Atrophy in the frontotemporal region where
  neuronal loss, gliosis, and masses of
  cytoskeletal elements are most present.

124
What isKluver-Bucy Syndrome?
125
Kluver-Bucy Syndrome

• 1 Hypersexuality
• 2 Placidity
• 3 Hyperorality

126
Kluver-BucySyndrome Caused By?
127
Kluver-Bucy Syndrome Caused By

• Damage to both medial temporal lobes.

128
Bradyphrenia?

• Means?
• And seen in?

129
Bradyphrenia

• Bradyphrenia is a neurological term referring to
  the slowness of thought common to many disorders
  of the brain.
• Disorders characterized by bradyphrenia include
  Parkinson's disease and forms of schizophrenia.
  Bradyphrenia can also be a side effect of
  psychiatric medications

130
Sundowner Syndrome?

• 1 Clinical picture?
• 2 Causes?

131
Sundowner Syndrome

• Clinical picture confusion and ataxia.
• Causes in demented patients when external
  stimuli, light or interpersonal cues are
  diminished.

132
Step-wise Cognitive Deterioration?

• Seen in?

133
Step-wise Deterioration

• Seen in vascular dementia

134
Alcohol withdrawal?

• Manifestations?
• Treatment?

135
Alcohol withdrawalManifestations

• Irritability, nausea, vomiting, insomnia,
  malaise, autonomic hyperactivity, shakiness

136
Alcohol withdrawaltreatment

• Fluids, sedate with benzodiazepines, 100 mg
  thiamine IM

137
Idiosyncratic AlcoholIntoxication?

• 1 manifestation?
• 2 treatment?

138
Idiosyncratic AlcoholIntoxication, Manifestation

• Marked aggressive and assaultiveness.

139
Idiosyncratic Alcohol Intoxication - treatment

• Protective environment.

140
Q. Alzheimers Diagnostic Markers
141
Ans. Alzheimers Diagnositc Markers

• 1 cortical atrophy
• 2 amyloid-predominant neuritic plaques
• 3 tau-predominant neurofibrillary tangles

142
Q. Markedly Diminishedin Alzheimers
143
Ans. Markedly Diminishedin Alzheimers

• Choline acetyltransferase
• Acetylcholine

144
Q. If need a benzodiazepinein treating
Alzheimers
145
Ans. If needing a benzodiazepine in treating
Alzheimers

• Go with short acting, lorazepam or oxazepam

146
Q. If Needing to use an antipsychotic?

• In pts with Alzheimers

147
Q. If needing to use an antipsychotic

• Ans. Select with low anticholinergic activity

148
Q. Pathology ofParkinsonians Disease?
149
Ans. Pathology of Parkinsonians Disease

• Pathology is especially seen in substantia nigra

150
Q. Parkinsons Halluncinations?
151
Ans. Parkinsons Hallucinations

• Visual

152
Q. Head TraumaPhysical Findings
153
Ans. Head TraumaPhysical Findings

• Ans.
• Blood behind tympanic membrane
• Subconjunctival ecchymosis raccoon eye sign
• Pupillary abnormalities

154
Q. Wilsons genetic finding?

• Which chromosome?

155
Ans. Wilsons Genetic Finding

• Ans. On chromosome 13

156
Q. Chronic Traumatic Encephalopathy signs?
157
Ans. Chronic Traumatic Encephalopathy - signs

• 1 Dysarthric speech
• 2 Emotional liability
• 3 Slow thinking
• 4 Impulsivity

158
Q. Compareas to cognitive severity

• Amyloid-predominant neuritic plaques?
• Tau-predominant neurofibrillary tangles?

159
Ans. Compare as toSeverity

• The plaques are more a sign of severity than the
  tangles

160
Q. Apolipoprotein?
161
Ans. Apolipoprotein

• Risk factor for Alzheimers but neither necessary
  or sufficient factor.

162
Q. Frontotemporal Neurocognitive Disorder

• Pathology?
• Name two types and associated pathology.

163
Ans. Frontotemporal Neurocognitive Disorder

• Behavioral-variant has both frontal lobes and
  anterior temporal lobes are atrophied
• Semantic language-variant has temporal lobe
  atrophy at the middle, inferior, and anterior
  parts of that lobe

164
Q. Wing-beating tremor?

• Seen in?

165
Ans. Wing-beating tremor,Seen In

• Wilsons

166
Q. Lewy BodyPathology?
167
Ans. Lewy Body

• The underlying neurodegenerative disease is
  synucleinopathy due to alpha-synuclein misfolding
  and aggregation.

168
Q. Tramantic Brain Injury

• Neurological/Mental Signs?

169
Ans. TBI

• loss of consciousness
• posttraumatic amnesia
• Disorientation and confusion
• Neurological signs, e.g., seizures

170
Q. Creutzfeldt-Jakob

• A form of?

171
Ans. Creutzfeldt-Jakob

• One of the prion diseases

172
Q. Huntingtons Disease

• Diagnostic marker?

173
Ans. Huntingtons Disease

• Genetic testing for trinucleotide CAG on
  chromosome 4.

174
Q. Hiranos bodies?
175
Ans. Hiranos bodies

• Seen in Alzheimers.
• Hirano bodies are intracellular aggregates of
  actin and actin-associated proteins first
  observed in neurons (nerve cells) by Asao Hirano
  in 1965.1
• Hirano bodies are found in the nerve cells of
  individuals afflicted with certain
  neurodegenerative disorders, such as Alzheimer's
  disease and Creutzfeldt-Jakob disease.2
• Hirano bodies are often described as rod-shaped,
  crystal-like, and eosinophilic.
• Hirano bodies have been noted as a function of
  age without obvious underlying neurodegeration